With approximately 1.3 billion births estimated to be taking place globally over a decade up to 2020, the demand for maternal and newborn health (MNH) workforce continues to be a key aspect of public health service delivery. Human resources for health (HRH) projection models can contribute the quantitative evidence required for policy design for education commissioning and distribution of skilled personnel. To date, HRH supply and requirement projection models have not been developed specifically for system-based subnational planning within maternal and newborn care. In addition, current methodologies are often limited to national level and have a professional silo approach to considering the workforce, with informing policy and planning as a secondary consideration. The aim of this thesis was to fill the gap through improved understanding of the role of HRH projections for policy and development of a new model for projecting the future MNH clinical teams with spatial equity and system perspective at the centre of the planning framework. The specific objectives were to • review the literature for strengths and limitations for current HRH planning and outline the main components of an evidence-informed MNH-HRH planning framework with relevance to subnational contexts and MNH systems • translate the main components into a working prototype as a spreadsheet-based model to estimate and MNH-HRH requirements and supply for each occupation • apply the MNH-HRH planning model in three countries from low to high income contexts and critique the implications for future research and development in this field. Following the construction of a new planning framework, a working prototype called the ‘MNH.HRH Planning App’ was developed. The spreadsheet-based model was applied using secondary data sources to England, Bangladesh, and Ethiopia which have varied health systems, levels of spatial disaggregation and HRH structures for MNH care. The thesis concludes by highlighting the implications of the new planning framework for the future development of a web-based MNH.HRH Planning App, potential for engaging policy-makers for evidence-informed planning and contributes to the wider discourse on the use of quantitative projection models for planning the future human resources for healthcare.

Measuring the strength of public health programmes may reveal whether and how some programmes have an impact on target populations and others do not. Programme implementation strength (also known as programme intensity) refers to quantitative measure reflecting programme inputs, processes, and their duration. Measuring programme strength requires an understanding of how programmes work and involves defining measurable concepts, identifying sources of programme data and close programme follow-up. There are no standardized methods for measuring programme strength. This thesis developed and tested an approach for estimating programme strength for use in evaluating large-scale maternal health programmes in low- and middle-income countries. It used focused antenatal care (FANC) and emergency obstetric care (EmOC) as tracer programmes, with WHO’s health-system-building blocks as programme components. The thesis used mixed methods including: developing a weighting scheme through opinions from maternal health experts, collecting FANC and EmOC data from 23 districts on programme strength, programme coverage, and programme contextual factors, using government official statistics, and using routine data from a central database. The thesis also tested the content and face validity of the approach. Results from experts showed that, even though all six WHO blocks were required in programme implementation, human resources was given relatively higher weights than the other programme components. While the overall programme strength in districts scored an average of 41% (FANC) and 40% (EmOC), the overall programme coverage scored an average of 80% (FANC) and 64% (EmOC). Contextual factors significantly associated with the programmes included: total fertility rate, female literacy, water, sanitation, and famine. The content and face validity were both rated “very good”. This work aims to contribute towards an efficient way of evaluating large-scale maternal health programmes in low- and middle-income countries. The approach could also be of interest especially to district health management authorities for improving health programmes.

Background: Women booked for home or GP unit delivery, under the care of their community midwife and GP, are frequently transferred to consultant care. Even obstetrically low risk women may develop complications which necessitate hospital-based intervention. Transfer has been perceived as undesirable and booking policies have been developed to avoid it, but few studies have focused on transfer from either a medical or a maternal view point. Objectives: To describe the community-based obstetric service, focusing on transfer, and to compare it with shared care; to investigate women's experience of transfer. Design: (1) A prospective comparative survey with non-equivalent controls, using ante- and postnatal postal questionnaires; the data were analysed using SPSS. (2) Long interviews 3 to 8 weeks postnatally, which were taped, transcribed and analysed according to grounded theory. Setting and subjects: All 122 women booked for GP unit or home birth in a northern English city in the second half of 1991; 141 controls were drawn from low risk women booking for shared care. The response rates were 82% and 62% respectively. Twelve transferred women were interviewed. Main outcome measures: obstetric intervention and outcome; maternal characteristics, preferences and satisfaction; continuity of care; length of stay; transfer rate and indications. Results: Community-booked women have similar obstetric outcomes to shared care women, but less intervention, better continuity and shorter length of stay. They have higher expectations but are more satisfied with their care. Overall transfer rates (46% in primiparous and 23% in multiparous women) resemble those in other units. Transferred women are especially vulnerable to disappointment, but continuity of care and sensitive debriefing ameliorate it. Conclusion: Transfer does not detract from the overall advantages of community based maternity care, but for the women it affects, special attention is needed.

This thesis presents the results of an empirically-grounded exploration of the ascendance of maternal mortality as an issue and its neglect by Brazilian public policy. Its purpose is to contribute to the existing scholarly debate on social policy and participation in order to advance knowledge on the dynamics of agenda setting and activism. More specifically, it relies on a case study of political and policy strategies aimed at maternal mortality reduction, to determine whether or not decentralisation has led to processes and environments that are more adequate to the advancement of women’s rights. Policy and discourse analyses are used to discuss the continuous appropriation, transformation and re-appropriation of decentralisation by the different policy networks and its influence in the depoliticisation of the wider human rights movement. In-depth interviews with key-actors participating in the 1980s and 1990s health sector reforms in Brazil demonstrate that decentralisation does not live up to its social justice premise and that, as it is not inserted into a wider culture of political measures for positive change, it reinforces existing power hierarchies and elitism. This historical analysis serves as a statement of the voracious power neoliberalism has over all types of policy making as well as its opportunistic advancement of certain political strategies created by different individuals and networks involved in the institutionalisation of human rights-based approaches. This control exerted by neoliberalism over policy and policy discourse is particularly acute in the case of maternal mortality. In its most progressive format, maternal mortality touches upon politically contentious issues that are often resisted by conservative networks supporting neoliberal control over public health sector reforms, principles and practices. Furthermore, in the face of new and multiplying policy spaces created by decentralisation, women’s rights networks lose their political leverage as sophistication, capacity and resources become indispensable.

Small numbers of pregnant women adhere to physical activity (PA) guidelines. Theoretically informed intervention may alter PA. Therefore, this research aimed to explore the effect of a theory-based (Health Action Process Approach, HAPA) intervention in reducing the magnitude of decline in PA during pregnancy. 109 primiparous, low risk women (mean age 29.9 +/-4.8 years) took part in an RCT in an urban maternity unit. Women were randomised to either usual care group or to intervention group, who received three individual PA consultations and an invitation to attend a weekly walking group after 20 weeks gestation. The primary outcome, change In PA, and secondary outcomes; mood, self-esteem, anxiety, social support, quality of life, perceived health, health service use, HAPA variables, gestational weight gain (GWG) and obstetric delivery outcomes were measured at weeks 10-14, 20-22 and 36-38 gestation. Ethical approval was granted by the Office for Research Ethics Committee, Northern Ireland (12/NI/0036) and the trial was registered (ISRCTN61829137). PA changes were analysed using Two-way Analysis of Variance (ANOVA) and Wilcoxon signed-rank tests. Changes in secondary outcomes were analysed using Repeated Measures ANOVA or chi square tests. Minutes of Moderate , and Vigorous intensity PA (MVPA) significantly decreased over pregnancy in both groups, however, the intervention group demonstrated a lesser decline with a median decrease of 3.5 minutes per day compared to six in the control group. Those attending at least one walking group (N=13) indicated a trend towards a lesser decrease in MVPA (attenders two and non-attenders four minutes per day). The intervention group showed greater increases in positive mood and less increase in anxiety (mood 2.4 vs 1.2; anxiety 1.9 vs 2.4). There were no differences in obstetric outcomes between groups. Results suggest that the intervention can reduce the decline in PA during pregnancy, however further testing is recommended.

Background: Telephone helplines have been implemented across the NHS in a drive to enhance service productivity and efficiency. They are a relatively new initiative in maternity care and to date few maternity units have introduced a dedicated helpline for women run by midwives alongside routine service provision. Currently there is a dearth of evidence regarding why women call helplines, whether advice and information offered as a consequence avoids the use of additional health resources or if helplines are viewed positively by healthcare providers. Aims and objectives: This study aimed to explore the use and impact of a maternity telephone helpline service established in one large London maternity unit from the perspective of women who called the helpline and healthcare staff based in three clinical areas which traditionally received high call volumes. The study also aimed to explore and understand the health or advice seeking behaviour of women who called the helpline. Study objectives were to identify the reasons for calls, describe the content, impact and outcome of advice on self care offered by the midwife, explore why pregnant and postnatal women sought advice, and explore views of healthcare staff regarding the role of the helpline with respect to impact on their area of care provision. Research design and methodology: Feminist epistemology influenced the study design framed within the health belief model. A case study design supported use of multiple methods of data collection in line with the epistemological and theoretical framework with three study phases. Phase one was a service evaluation that involved collating routine data using a prospective cohort of 422 women, 50 community midwives and four partners who called the helpline during a one month period. Phase two comprised telephone interviews with a purposive sample of 34 women offeredadvice on self management of reported concerns and a purposive sample of women who called the helpline on more than one occasion. Face to face interviews were conducted during phase three with a purposive sample of 11 healthcare workers to explore their views of the helpline. Analyses included univariate approaches of quantitative data and thematic analyses of qualitative data. Key findings: Women called the helpline for concerns ranging from individual pregnancy and non-pregnancy related health problems, to requests for information on aspects of routine maternity service provision. Reasons for calls supported constructs of the health belief model. The advice offered appeared to avoid the need for additional health contacts, reassured women and enhanced confidence and self efficacy. The need to revise information systems was highlighted by the extent to which the helpline supported the organisation, when routine systems were not adhered to by staff. The helpline was perceived by health professionals and clerical staff as potentially reducing unscheduled admissions and ’freeing’ up time to focus on other aspects of clinical care and work practices. Conclusion: Findings contribute evidence on how a maternity helpline offers support and reassurance for women, building confidence, self-efficacy and potentially reducing need for additional health contacts. Healthcare staff viewed the helpline positively, with the need for services to ensure that strategies for communication and information provision are revised appropriately. Further larger studies are now required to consider outcomes of maternity helplines.

The aim of this research study was to introduce and examine the effects of a change to a system of Patient Allocation in a ward of a Maternity hospital. The study examined in particular the relationship between the organisation of the delivery of nursing care and three organisational outcomes which, in the nursing literature are reputed to be improved when a system of patient Allocation is used. These organisational outcomes are; 1) patient Satisfaction with care 2) The Job Satisfaction of the nursing staff 3) The nurse-patient relationship A review and analysis of the literature suggested that methods of organising the delivery of nursing care - Task Allocation and Patient Allocation - tend to be seen as mutually exclusive 'ideal' types and that they tend to be associated with different paradigms of care. In this study descriptive, experimental and action approaches were used and the data was obtained from two areas of investigation. 1) An experimental study whereby one ward introduced the new method of delivering care. 2) A series of interviews with the nurses and midwives who had worked in the ward where the changes were introduced, and in other wards of the hospital. Questionnaires, interviews and non-participant observation were the main instruments used to collect the data. The data obtained in the study provided little evidence to support the reputed advantages of a system of Patient Allocation. Two explanations for the results were suggested. 1) The use of Task Allocation and patient Allocation as mutually exclusive 'ideal' types has led to the image being confused with the reality. 2) Change from a system of Task Allocation to patient Allocation should be seen as a process and not an event.

This thesis is the product of an ethnographic discourse analysis of midwifery talk and practice, and the data used to inform-this work was collected in the south-east of England. The analytical focus of the thesis is on how risk is understood within the context of midwifery knowledge and expertise and how this is expressed within contemporary childbirth performance. The proposition being made is that the meaning of risk should not be taken as a given and that, although much of routine midwifery activity circulates around sensitivity to risk, the precise meaning of risk is rarely articulated or questioned by practitioners. By using a combination of both qualitative methodological and analytical devices, it has been possible to explore the social and political operations of the interpretative work midwives do when translating risk into meaningful action and the impact this has upon the way birth can be both imagined and performed.

In the United Kingdom midwives have a key role in caring for women and their families throughout the childbirth continuum. Midwifery is assumed by many to be both an ‘art’ and a ‘science’. The term ‘midwife’ comes from an Old English phrase ‘with woman’ with an expectation of holistic or ‘whole person’ care. At the same time there is some concern that movement of midwifery training into higher education institutions has led to an erosion of the skills associated with the art of midwifery due in part to students not being taught in an holistic way, with more focus on the need for academic achievement combined with a greater emphasis on the ‘science’ of midwifery. Little research exists that addresses what being a midwife means to those who have this role, or their view of the art of midwifery. This study aims to explore these issues with a group of nine women who are midwives, who had been part of an educational session that used creative methods to facilitate learning about the art of midwifery. Within the study the midwives are recognised as ‘whole’ people, with physical, emotional, spiritual and social aspects of themselves. Their views and experiences are explored in a qualitative ‘organic’ way utilising the concept of ‘bricolage’ and use of creative methods in order to address the multi-dimensional nature of the person . Material for the study was obtained through collection of written personal histories and created pieces used in the educational setting, semi-structured interview and photo-elicitation montages. Individual text ‘quilts’ have been created from the participants’ expressions that provide a visual representation of meaning. This has enabled a different, more ‘playful’ multi-dimensional approach to the material. Further, in recognition of the author also as woman/midwife/educator/researcher, an autoethnographic approach has been taken, using a reflexive research diary, with a textile quilt created from abstract squares made as a response to individual diary entries. All these aspects have been integrated in the bricolage of the thesis. The thesis demonstrates how the use of creative methods facilitates a more ‘rounded’ approach to qualitative research. The participants identify complex meanings to being a midwife, related to their identity; ‘who’ they are in opposition to ‘what’ they are. This is balanced with choices made in relation to family commitments. The essence of a midwife is valued as important for what it is as well as for its impact. These meanings relate to the physical, emotional, spiritual and social nature of the role. In addition they view the art of midwifery to be grounded in a natural approach to the woman and her unborn baby, often in an increasingly technological environment. Birth is viewed as a significant event. Community practice is viewed as the ideal environment for providing midwifery ‘art’ and they highlight the need for intense trusting relationships with women and recognition of intuitive knowledge in their practice. This is balanced with views about safety and reflections on complex, often distressing situations that are faced in everyday practice. Being a midwife involves powerful emotions, for which they require greater support. They further raise issues of lack of time, some conflict in relationships between midwives, lying about their practice and effects of the ageing process on their role.

In the current study, the effective content of routine care during pregnancy was investigated from women's points of view in three European countries: the Netherlands; Scotland and Switzerland. The participants were 32 women who were either pregnant at different stages of uncomplicated pregnancies or mothers within a year after giving birth. One-to-one semi-structured interviews were used to explore their views, while related documentary material in each of the countries was collected in order to increase understanding of women's experiences of care during pregnancy. Through the grounded theory approach of Strauss & Corbin (1998), using language units to assess meaning, the complexity and magnitude of the research area was captured. Within each of the units, grounded theory led sampling, data collection and analysis.